Medicare: Even Rocket Scientists Can Find Understanding It Convoluted and Confusing. To the Rescue: “Medicare 101”
By Becky Feola
NABBW’s Associate for Assisted Living and Caregiving
The program Medicare is easily one of the most recognized senior benefits in our nation.
However, it can be confusing and many people don’t understand the basics of how the program works.
Below is an overview that should give some clarity and guidance if your loved one ever needs care.
Medicare is the federal health insurance program for people who are 65 or older or those who may be younger but have certain disabilities, and people suffering from End-Stage Renal Disease (permanent kidney failure that requires dialysis or a transplant).
Medicare Part A – 90 days of care in the hospital for each benefit period, plus additional lifetime days
- Coverage begins when you are formally admitted to the hospital. Beware: you are not covered if you are there for observation and have not been admitted.
- Care is covered in a skilled nursing or rehabilitation facility for up to 100 days per benefit period, only if it is preceded by at least 3 midnights of having been admitted to the hospital.
- Skilled care is covered as long as it is deemed “medically necessary” to help you maintain your current level of health and you do not have to demonstrate improvement.
- There is no premium, but there is a co-pay for in-patient care in the hospital and after the first 20 days.
- A new benefits period begins when you have been out of the hospital or skilled nursing facility for at least 60 days in a row.
- Part A covers home care after being discharged from a hospital or skilled nursing facility if ordered by a physician.
- Supplemental insurance will cover all or part of the deductible and/or co-payments but it does not cover services or time in the hospital that Medicare does not cover.
Medicare Part B – Doctor’s Visits
- A premium is deducted from your social security payment.
- You must sign up when you turn 65 or the premium may be higher when you do.
- There may be deductibles and co-pays that your supplemental insurance might offset. Part B does not cover services not provided by Medicare.
Medicare Part C – Medicare Advantage Plans
- Each plan can charge different out-of-pocket costs and have different rules as to how you receive services, but they must follow the rules set by Medicare.
- You will usually received prescription drug coverage (Medicare Part D) through the plan you choose. If the plan you choose doesn’t offer drug coverage, you can join a Medicare Prescription Drug Plan.
- You cannot have drug coverage through both the Medicare Advantage Plan and a Medicare Prescription Drug plan.
Medicare Part D – Prescription Coverage
- You must contract with a private insurer during specific enrollment periods. If you do not sign up when eligible, premiums may be higher.
- There may be co-pays for a period of time each year when there is no insurance coverage.
Key Information to Remember:
- You must be admitted to the hospital. Staying overnight does not equal admission. Your doctor must order the admission and the hospital must formally admit you.
- If you have not been admitted to the hospital, the hospital may be reimbursed per the applicable rate under Part B for certain services, but your stay in the hospital will not be covered and your time at the hospital will not count towards the 3 midnights necessary for Medicare to cover skilled nursing or rehabilitation.
- Make sure that you or your family ask and receive proof that you have been admitted.
Becky Feola is the founder of Assisted Living Advantage, located in Phoenix, Arizona. She started her company in 2009, after working for four years as director of the non-profit NJF Center for Caregivers, Inc. Becky has personally been through the process of relocating a loved one to assisted living – more than once.
Her passion for assisting others in locating care facilities for their loved ones comes after eleven years of providing care for her ailing husband and then realizing it was time for assisted living. After her husband was diagnosed with Huntington’s disease, she became his primary Caregiver. She immersed herself in research, learning all that she could concerning the disease, the legalities of being an informal caregiver and guardian, the insurance companies, social services, and the legal system.
She has personally seen how difficult it can be to find the perfect care facility without the assistance of someone who understands issues such as licensing, levels of care, and appropriate pricing. Becky views herself as a “matchmaker” and is determined to create the perfect match where your loved one will move one time only to a new home where they will thrive as much as possible during their remainder years. She puts her understanding, vast knowledge of the Phoenix area and her exacting standards to work for her families, with excellent results.